A variety of the most common spinal disorders are frequently encountered at ANA. We work with our patients to carefully evaluate these conditions, and we seek to exhaust all non-surgical solutions before considering surgery.
The anatomy of the spine includes vertebrae that are stacked on top of one another. This provides both protection of the spinal cord, as well as a flexible support structure that enables movement.
There are seven vertebrae in the neck (cervical vertebrae), 12 vertebrae in the mid-back (thoracic vertebrae) and five vertebrae in the low back (lumbar vertebrae). These vertebrae are all separated by protective discs, which are padding that acts as cushions between each vertebra. Each disc has a soft, jelly-like inside surrounding by a tough outer layer.
When one of these discs ruptures for whatever reason, it is called a disc herniation. However, disc herniation is a condition that is referred to by a number of different and names often used interchangeably. These names include:
- Bulging disc
- Herniated disc
- Pinched nerve
- Prolapsed disc
- Protruding disc
- Ruptured disc
Despite the number of terms, all of these names still define the two basic types of disc herniation:
- Contained disc herniation where only the tough outer layer is involved
- Non-contained disc herniation, which occurs when the break in that outer layer results in some of the soft inside protruding out of the disc
Symptoms of a Herniated Disc
The majority of herniated discs occur in the lumbar spine (lower back) but can also occur in the cervical spine (neck). While herniated discs can result in problematic symptoms, there are cases in which disc herniation is revealed in imaging studies in people without any symptoms.
In those who are symptomatic, herniated discs can cause the following:
- Muscle weakness in the affected area
- Pain in the back arm, leg or foot. A herniated lumbar disc causes pain typically felt in the leg and/or and buttocks. A cervical herniated disc results in arm or shoulder pain.
- Tingling or numbness sensation in the affected area
Diagnosis of a Herniated Disc
The diagnosis of a herniated disc consists of several phases. The first is a medical history and physical exam done by a doctor. In this exam, the doctor will check for back pain. He/she may palpate certain areas to determine the precise location of the pain and also perform reflex and muscle strength tests. The patient is asked about the nature of the pain (e.g., throbbing versus dull), if they experience any tenderness and which positions or activities increase or lessen the pain. Past treatments for the condition will also be reviewed.
In order to confirm or clarify a diagnosis, and to obtain additional information, imaging tests may be ordered. These include:
- Computed tomography (CT) scan
- Magnetic resonance imaging (MRI) scan
Surgery for a Herniated Disc
Before considering surgery, all nonsurgical treatments should be exhausted. These may be used separately or in conjunction with one another. These treatments may include:
- Epidural injections
- Heat and ice therapy
- Nonsteroidal anti-inflammatory drugs or other pain medications
- Physical therapy
If these treatments are not effective over time, and pain and other symptoms disrupt activities of daily living, surgery may be a consideration. The most common surgery for a herniated disc is a discectomy. In this procedure, either part or the entire disc is removed. Using minimally invasive surgical techniques, it requires only tiny incisions through which specialized instruments are inserted to remove the damaged tissue with the aid of a microscope.
This technique shortens surgery time and minimizes tissue and muscle disruption and any possibility of risks or complications. In most cases, a discectomy can be done on an outpatient basis.
Recovery from Herniated Disc Surgery
At one time, when open surgery was the only option for herniated disc surgery, recovery was extensive. With the advent of minimally invasive surgical techniques, however—which are performed with limited muscle or tissue involvement— procedures may be performed on an outpatient basis. This means recovery is much quicker and the patient may go home the same day following surgery. Often, physical therapy starts the next day. In the meantime, pain or discomfort is usually temporary and restricted largely to the incision sites.
The road to full recovery depends on the individual patient as well as his/her general health. Many patients can return to work (non-physically demanding jobs) in a week, and make a full recovery with return to normal activities by six weeks.
The surgeon will provide a detailed recovery plan with detailed instructions that guide every patient in terms of expectations for recovery and resumption of activities.
Degenerative disc disease
To understand degenerative disc disease (DDD), it is helpful to review the anatomy of the spine.
The spine is a remarkable combination of design and functionality that helps our body as a shock-absorber for the stresses of movement, and at the same time provides the flexibility to move in all directions. It is composed of the vertebral column, otherwise known as the backbone. There are 33 vertebrae, separated by protective discs. These discs include a cartilage outer band and a gel-like inner substance.
With age (wear and tear), injury or disease, discs lose their protective properties: their shock-absorbing and flexibility capacities. When this occurs, it can become problematic and painful.
Although it is called degenerative disc disease, it is not a disease in the traditional sense. DDD is a natural process that happens over time. By age 35, about 30 percent of the population has some disc degeneration at one location or another. By the age of 60, that number jumps to 90 percent. A diagnosis of DDD is considered for people who have symptoms of pain due to disc degeneration.
DDD can affect any part of the spine, but it most commonly affects the low back (lumbar spine) or neck (cervical spine). Most people with DDD have neck and back pain.
This pain has particular patterns, such as worsening with prolonged sitting, or when twisting, bending or lifting. The pain may abate with movement, changing positions or lying down.
Common symptoms include:
- Pain that worsens, is described as cramping or throbbing and/or burns when it radiates to the extremities
- Tingling or “pins-and-needles” feeling
- Numbness or weakness of the muscles
- At severe stage, loss of bladder or bowel control
Arriving at a diagnosis of DDD follows the customarily thorough path. The doctor reviews the patient’s medical history, seeking to determine both the source of the symptoms and the risk factors (including a family history). A full review of symptoms includes determining when and how those symptoms worsen.
This is followed by a complete physical exam to determine the location of the problem. A test of function, including range of motion and reflexes, also helps narrow down the criteria for diagnosis.
Finally, imaging tests are used to confirm a diagnosis and rule out any underlying problems, such as a fracture or tumor. Common imaging tests include X-rays, computed tomography (CT) or magnetic resonance imaging (MRI).
Making a DDD diagnosis can require additional tests. These include:
- Myelogram to view any spinal cord abnormalities
- Nerve conduction study and electromyogram (EMG) to pinpoint the origin of symptoms
- Discogram to check for disc dysfunction
Spine surgery has significantly improved since the 1990s, with the use of video imaging for surgery. That progress has continued with the advent of advanced microsurgical techniques. These have created the possibility for much less invasive surgery, with fewer potential risks and complications.
Nonsurgical methods of treatment include over-the-counter or prescription medications, physical therapy and lifestyle changes. However, if after months of this treatment, pain and other symptoms are still significant and quality of life is seriously impacted, a surgical consultation is recommended.
There are two categories of surgery, decompression and stabilization. These are often done simultaneously, and can include a microdiscectomy. Various relevant surgical options (minimally invasive surgery, microdiscectomy and fusion) are described here.
While surgical incisions heal within a week or two, general recovery from a procedure such as a microdiscectomy can take one to four weeks. It may take a more significant amount of time, at least several months, to heal from fusion. Recovery means limiting activities and usually also includes undergoing physical therapy.
However, this does not mean activities cannot be modified. Light work duties may possibly be resumed in a week or two, while more significant activity, including exercise, may require four to six weeks.
A surgeon instructs patients carefully on recovery, creating a customized plan depending on the type and extent of the surgical procedure and the age and general health of the patient.